Basic Information
| Provider Information | |||||||||
| NPI: | 1285205427 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MCINTOSH | ||||||||
| FirstName: | WYLISA | ||||||||
| MiddleName: | M | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | LSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 212 S SUMMIT ST | ||||||||
| Address2: | |||||||||
| City: | INDIANAPOLIS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 462013963 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7736538548 | ||||||||
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| Practice Location | |||||||||
| Address1: | 5638 PROFESSIONAL CIR | ||||||||
| Address2: | |||||||||
| City: | INDIANAPOLIS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 462415042 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8887141927 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/08/2021 | ||||||||
| LastUpdateDate: | 07/08/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 07/08/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X | 33010286A | IN | Y | Behavioral Health & Social Service Providers | Social Worker |
No ID Information.